Please complete and bring the following forms to your child’s first visit:
- Patient Registration and History (one per child)
- Responsible Party Information (one per family)
- Please read the following Notice of Privacy Practices (read only)
- Finally, please bring the Acknowledgement of Receipt Form (one per family) with you.
We look forward to meeting you and your child! Feel free to bring a favorite CD or DVD!
State of Illinois Proof of School Dental Examination Form
- School Dental Exam Form – This form is required by Illinois State Law for Kindergarten, second, and sixth grade students. We are happy to complete this form for you.
Referral Form for Referring Doctors
- Patient Introduction Form for Referring Doctors – We love referrals. We thank you for the confidence that you place in our team and for helping our practice grow.